Provider Demographics
NPI:1508848979
Name:VELASCO, MAURICIO (MD)
Entity Type:Individual
Prefix:DR
First Name:MAURICIO
Middle Name:
Last Name:VELASCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-3112
Mailing Address - Country:US
Mailing Address - Phone:201-864-3456
Mailing Address - Fax:201-869-7224
Practice Address - Street 1:6500 BROADWAY
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-3112
Practice Address - Country:US
Practice Address - Phone:201-864-3456
Practice Address - Fax:201-869-7224
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07598200207R00000X
NY2342401207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0060437Medicaid
NJ078853Medicare ID - Type Unspecified
NJ0060437Medicaid
NY261AV1Medicare ID - Type UnspecifiedMANHATTAN